System thinking in a personal context, page 1

System Thinking in a Personal Context

Farrokh Alemi, Ph.D.

Lisa Pawloski, Ph.D.
William F Fallon, Jr., M.D., FACS
Nancy Tinsley

Chapter 3 in “A Thinking Person’s Weight Loss and Exercise Program”

We acknowledge the assistance of Mary Fittapaldi, who helped us sharpen the arguments in this chapter. A pPortion of this chapter is based on F. Alemi F, L. Pawloski L, and W. F. Fallon WF, Jr.,2003, " System Tthinking in a personal Personal context Context to Iimprove E eating Bbehaviors,." Journal of Healthcare Quality. 2003,25(2) (Mar.-Apr.);25(2): 20-–25.

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Introduction

Earlier in this book we suggested that weight loss and increased exercise can be accomplished by making systemwide changes and de-emphasizing personal exhortations. Little is known, however, about what is meant by systemwide change, especially in the context of personal change. We tackle this problem here. The chapter lays out ways to distinguish systemic change from personal effort, and provides a case study and numerous other examples to clarify the task of bringing about systemic changes in one’s lifestyle.

We and others have used the terms “system thinking,” “system change,” “ecological change,” “environmental change,” “lifestyle changes,” and “structural changes” interchangeably. These words are used often and without a precise definition. Naturally, the first step is to define these terms and to distinguish the changes they describefrom change through increased personal motivation, increased effort, and more commitment. We define system thinking—and all related words—as the process of accounting for the influence of various people, circumstances, and historical choices on the behavior we wish to modify. System thinking is the process of understanding how people and circumstances are linked. Many people have heard that they should change their lifestyle but are not clear about what this means or how the change is to be accomplished. We believe that everyone’s life is organized as a system of interrelated events, people, and influences. Making a system change is the same as creating a new lifestyle—these are different words for the same idea.

“An ecological approach regards obesity as a normal response to an abnormal environment.” (Johnson 1990)

Individuals are affected more by their own choices than by others. If a person decides to live far away from work and commute, he or she may not be able to exercise as much as he or she wants. Thus one can see that the earlier decision of where one chooses to live or work can affect one’s exercise patterns. System thinking helps to see how earlier choices may limit later options.

A key component of system thinking is the recognition of the environment's lasting and silent role in behavior. Every person is affected by his or her environment. Even people who live alone are connected to their environment—and through the environment to other people. Take for example an asthmatic who lives by himself. He may be alone but others still influence his behavior: pollution in the air affects his breathing, which affects his ability to exercise, which affects his metabolism and his food intake. In the end, the very air around him connects him to others and opens him to persistent influences. In our view there is no exception to this rule. All people are linked to their environment and to others. No one is isolated.

In this book, we use the concept of system thinking in a personal context. The words personal and system, at first glance, seem contradictory: Personal focuses on the individual, while system implies a world of interacting events beyond the individual's realm of control. Juxtaposing these words helps us emphasize that humans live in a complex mesh of activities. Each activity is affected by the individual’s decisions—and likewise the environment, the system around us, triggers changes in our behavior. It is personal in the sense that it is a unique set of circumstances that we live in and it is a system because it involves others and many factors beyond a person’s control.

Alemi et al. (2000) gave anparticularly demonstrative example, mentioned earlier in this book, regarding system thinking. In this example, a person opens the refrigerator, pulls out a piece of cheesecake, and eats it. However, this person did not make this decision immediately, or just by himself. Part of the decision to eat the cheesecake was made earlier through previous choices. Where he lives, how often he exercises, how much he works, what he purchases at the store, with whom he eats, and a host of other earlier choices affected this person’s need to eat the cheesecake. Many people might eat the cheesecake and needlessly admonish themselves for failing to stay with their diet. Unfortunately, they are attacking the wrong decision, which may not help in keeping their own resolutions. They should focus on what made their options limited to the cheesecake rather than focusing on the cheesecake itself. System thinking can assist in redirecting our focus to the real problem.

Table 1: System Thinking Is Not Built on Slogans but Problem Solving
Examples of advice based on increased commitment: (These examples seem confusing as the facts are good, positive feedback is good but here refered to as increased emotion)
  • Face the facts; you have been fooling yourself
  • Give up the pleasure you receive from eating, in return for better health
  • Accept that losing weight will be a good thing
  • Set firm limits on areas such as sweets
  • Stop making excuses
  • Delay satisfying your urge to eat
  • Make sure you are hungry and not just tired, thirsty, nervous, stressed, or upset
  • Slow down your eating, you will eat less
  • Positive feedback from yourself or others will keep you on track
  • Close your eyes and eliminate sensory stimulation, it can help you focus your thoughts to what you need to do

Perhaps the best way to define system thinking is to describe what it is not. We asked a colleague to describe how she loses weight. She gave a description provided in Table 1. If you examine her advice, you see very common themes. You see repeated slogans urging the individual to remain committed. It is as thought the individual has to compel and pressure himself/herself to keep up with a diet or regimen. The vocabulary is one of controlling urges and restricting behaviors. In the end, the person is fighting himself or herself. The enemy is within. The focus is to tame one’s desire. System thinking is different. System thinking is about changing the environment and then letting the new world you have created guide you. When the environment is reorganized, weight loss is not about resisting but accepting and fitting in.

Current Approaches Are Not Working

In the United States, billions of dollars are spent each year by individuals trying to lose weight. Yet approximately one in three adults is obese (check), and overweight and obesity rates are rising. Few solutions appear to have an effect on the spread of obesity. Most medications and surgical procedures are not effective, unless a person adheres to a nutritious diet and incorporates an exercise program in conjunction with these therapies. Diet and exercise regimens are not working as many people cannot keep up with their own resolutions. And while many Americans are careful about reading food labels and purchasing foods that are low in fat and calories, they are still getting fatter.

Most of us knowwhat we are doing wrong. We know that large portion sizes are not healthy, we know that snacking often is not good for us; we know that drinking too many sweetened sodas is not reasonable. We know this and more. We know that we do not exercise enough. Though we are aware of the problem, we are unable to solve it. The advice to people who want to lose weight, as noted in this book's Introduction, is straightforward: eat less and exercise more. The controversy arises concerning how to follow this advice. What we do not know is how to keep at it. The real issue is how to lose weight and keep if off, since many individuals lose weight temporarily, only to gain it later.

A recent study by Dunn and his colleagues (1999) showed a way out of the cycles of repeated weight loss and weight gain. These researchers demonstrated that obesity management might benefit from a program that emphasizes system thinking and environmental changes. In their study, elderly patients who made systemic changes in their environment had the same weight and health outcomes as patients who actively participated in exercise programs delivered through free gym memberships. This study was particularly important because its two-year follow up period showed a lasting impact of systemic changes. The study thus raised the possibility that long-term weight loss could occur through simple environmental and lifestyle changes without a commitment to rigorous diet or exercise programs.

In 2000, we studied how system thinking might help people improve personal habits. We showed that 83 percent of people exposed to ideas behind system thinking (some followed it, some did not) were successful in achieving their resolutions in a 15-week period. The study provided additional data on the importance of an ecological model of obesity and excessive weight.

In the previous chapter, “Does It Work?” we provided additional data regarding the experience of nearly 200 participants in our classes. These data show that participants who made system changes in their lives were several times more likely to accomplish their goals. In sum, sSystem thinking might be a solution to a problem that we have not been able to solve for decades.

Beyond the Precede-Proceed Approach

Applying system thinking to personal issues is not a new idea. In 1990, Green and Kreuter suggested one of the earliest methods to come out of system thinking principles. They called their approach the Precede-Proceed model, emphasizing that people should look at what precedes a behavior and what follows to understand the barriers and reinforcements. Their approach focuses personal improvements on three key areas:

  • Predisposing factors. These include knowledge, attitudes, beliefs, and sense of self-efficacy.
  • Enabling factors. These are infrastructure factors such as equipment, reminders, availability of time, and so on.
  • Reinforcing factors. Examples include positive comments from friends, data on weight loss, rewards, helping others, and incentives.

Clinicians and public health professionals use the precede-proceed approach to understand behavior. We advocate a method of system thinking that goes beyond the work of these investigators.

Description of Case Study

To exemplify how system thinking can be used in a personal setting, we will use a recent case in which a physician taking a course at GeorgeMasonUniversity was able to reduce the his junk food consumption by joining a car pool. How could joining a car pool affect one's diet? On the surface, the two seem unrelated. But an analysis of this person’s life established a relationship between these two events. He was able to see that his junk food habit was affected by various work and home habits. Working late, for example, was interfering with his ability to find the time to cook, which led to a counterproductive cycle whose details are provided below and shown in Figure 1. Armed with this kind of knowledge, our student was able to break the cycle and reduce his junk food intake. Joining a car pool, since it had a fixed schedule, forced him to leave work on time. We will use his case to demonstrate how system thinking can bring new insight to people who want to go on diet or exercise regimens.

The student in our case study used the steps that we proposed in the workbook (Chapter 1). He selected a team of process owners, set goals that would benefit the entire team, described his personal system of life, polled the team for a list of ideas (making sure these would address the system, not one's own activities), decided to undertake a change, monitored the change by gathering data, and continued to tinker with the system as necessary, all the while keeping his story and progress out there for the team to follow and comment on.

Principle 1: Look to the Environment

System thinking starts when a person looks beyond his or her motivation and examines the environment. By environment we mean people and machines and buildings and weather and whatever other factors that might affect diet or exercise. Most people who decide to diet and exercise emphasize their motivation. They come up with resolutions such as the following: I am going to eat less. I am going to count calories. I will follow my diet. I will exercise more. A person can say he or she will do something, and will mean it, yet will not be able to do so. An individual can beat himself into frenzy over a resolution, but unless a positive environment is created the resolution will be difficult to keep over time.

A more sustainable approach is to change the environment and search for system solutions—not personal exhortations. When a person emphasizes motivation and willpower he is not examining how the world affects him. Certainly motivation matters, but what makes it remain a constant force and what brings about willpower is the environment. Creating a positive environment can lead to success even if a person is not fully motivated. This type of environment ensures that a person retains healthy habits. In contrast, a poor environment can eventually lead to failure, no matter how hard a person tries. To really succeed, in a way that is sustainable, there needs to be a change in the system. System thinking starts when one seeks solutions and causes in the environment—not in one’s commitment or motivation.

Obviously, to change the environment you need to be motivated. But this is a different kind of motivation. When you are dieting by relying on your own motivation, you need to constantly tell yourself what you want, you need to be vigilant and committed, every slip-up matters. When you change the environment, you are still working on your motivation but indirectly. Now the motivation emerges because of the new environment; even if you are not vigilant, it still influences you. So you do not need to remain terribly motivated, the world around you takes care of that.

Principle 2: Focus on the “Steady State”

The previous principle emphasized that a system is a wide open concept and entails everything in the environment. But it is not reasonable to try to conceptualize everything, and no one can do so without heroic effort. To say that everything affects a person’s diet is not effective analysis—it's paralysis. We need to simplify system thinking, make it more practical. One way to do so is to focus on recurring routines and events in the environment—not just bad habits but also all life routines.

While systems are expansive, one identifiable aspect of a system is that it is an organized structure with recurring characteristics—it is not a random heap of events. Analysts like Feller (1968) refer to these recurring events as the “steady state” of the system. A daily routine can articulate the organizing principles of an individual’s life. By listing these routines, a person can see the steady state for his or her system of life. The process reveals the direction in which he or she is heading (and will continue to do so, if no new influences are introduced).

Most people sleep and wake up according to a routine schedule. Even end-of-week socialization and partying follow certain routines. Many events happen periodically—some daily, others weekly, still others with longer periods. A key principle in system thinking is to focus on these periodic events. It is not that non-routine events do not matter—they do. But their effects are unlikely to assist in making permanent changes. One way to examine a person’s daily routine activities is to make a list of periodic events. Table 1 in Chapter 5 shows one such list.

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Figure 1: Shopping and Meal Preparation Are Related

Figure 1: Shopping and Meal Preparation are Related

Once routines have been listed, it is important to examine cycles among them. Systems naturally return to their steady state. When life styles are examined, it is important to find these steady states and understand how they occur. Life routines are interrelated. For example, what you eat is related to what you shop for and vice versa (see Figure 1). These linked routines are called cycles and providethe building block of life styles. We can change our lives by changing the cycles among repeating events. Cycles create inertia and resistance to change in the sense that if one element in the cycle is changed, the rest resist the change and encourage a return to old habits. So if you change your food habit but not your shopping habit, then the relationship between these two routines encourages relapse to old habits: Oold shopping patterns encourage a return to old eating habits. In this sense, there is a conspiracy among life routines. They all work together to defeat our efforts to change our life style. They work together to continue current habits. Understanding where life cycles are occurring is one of the first steps in understanding life styles and bringing about lasting change in them.

Cycles among the routines are not always apparent. Some are complex and involve several routines. Figure 2 shows the cycle for the case study in this chapter involving work, sleep, and eating routines.

Figure 2: A Cycle Connecting Work, Sleep, and Diet Routines